Failure to Implement Care-Planned Reacher Intervention for Fall Prevention
Penalty
Summary
The deficiency involves the facility’s failure to implement a care-planned fall prevention intervention for a resident identified as at risk for falls. The resident had multiple diagnoses, including congestive heart failure, schizoaffective disorder bipolar type, morbid obesity, hypertension, major depressive disorder, dementia, COPD, weakness, and physical performance limitations affecting balance, gait, strength, and endurance. The resident’s fall CAA documented that falls were triggered secondary to impaired gait and mobility and the level of assistance required with transfers, with contributing factors including a history of falls prior to admission and multiple comorbidities. The resident’s care plan and Kardex specified an intervention that the resident was to have a reacher within reach while in bed, and the resident had sustained a fall from bed earlier in the month. On multiple observations by the surveyor while the resident was in bed, a reacher was not within the resident’s reach despite the care plan requirement. The reacher was observed propped against a wall behind a box near the television, approximately four feet from the bed, and the resident reported not having a reacher while in bed on the prior day. Staff confirmed that the resident should have a reacher while in bed and acknowledged moving the reacher away from the resident that morning. The RN/Unit Manager confirmed that staff are expected to follow the Kardex and care plans. The Nursing Home Administrator and DON were informed of the surveyor’s observations, and no explanation was provided as to why the resident did not have the reacher within reach while in bed as required by the plan of care.
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